The endoscopic ultrasound probe findings in prediction of esophageal variceal recurrence after endoscopic variceal eradication therapies in cirrhotic patients: a cohort prospective study

Non-Invasive versus Invasive Assessment of Portal Hypertension in Chronic Liver Disease

Background

Cirrhosis is one of the major causes of morbidity and mortality worldwide and the second leading cause of digestive disease mortality. Portal hypertension is the main driver of cirrhosis-related complications such as ascites and variceal bleeding. Portal hypertension is defined as a hepatic venous pressure gradient >5 mm Hg, although it is clinically significant and associated with clinical complications when >10 mm Hg.

Summary

Therefore, detection of clinically significant portal hypertension (CSPH) in chronic advanced liver disease or compensated cirrhosis is of paramount importance to guide the management of these patients.

Key Messages

This study aimed at revising the non-invasive and invasive tools for assessment of portal hypertension and risk stratification for CSPH in patients with chronic liver disease.

Endoscopic ultrasound in portal hypertension: navigating venous hemodynamics and treatment efficacy

Portal hypertension-related complications increase mortality in patients, irrespective of its etiology. Classically, endoscopic ultrasound (EUS) was used to assess the portal venous system and collaterals, considering size and hemodynamic parameters, which correlate with portal hypertension (PH) and related complications. Furthermore, therapeutic EUS guides treatment interventions, such as embolization of the gastric varices through coil placement and tissue adhesive injection, yielding encouraging clinical results. Recently, the direct measurement of portal pressure, emerging as an alternative to hepatic venous pressure gradient, has shown promise, and further research in this area is anticipated. In this review, we aimed to provide a detailed description of various possibilities for diagnosing vascular anatomy and hemodynamics in PH and actual knowledge on the EUS usefulness for PH vessel-related complications. Also, future promises for this field of endo-hepatology are discussed.

The impact of restrictive blood transfusion on the safety of patients with esophageal varices after endoscopic variceal ligation: A single-center retrospective study

An investigation was conducted to examine the impact of restrictive blood transfusion on the safety of early rebleeding following endoscopic variceal ligation (EVL) in patients with liver cirrhosis. Data were collected from patients with cirrhosis and esophageal varices who underwent EVL at the Affiliated Hospital of North Sichuan Medical College between September 2021 and March 2023. Clinical information, including serum albumin levels, hemoglobin (Hb) levels, liver function classification, and the occurrence of early rebleeding, was recorded. Patients were divided into 2 groups based on their Hb levels: 60 g/L to 90 g/L (restrictive blood transfusion) or Hb ≥ 90 g/L after EVL. The impact of restrictive transfusion on the post-ligation safety of EVL was observed. A total of 246 cirrhotic patients were included in the analysis. Significant differences were found in Hb levels, liver function classification, early rebleeding rates, length of hospital stay, and hospitalization expenses between the restrictive transfusion and Hb ≥ 90 g/L groups. The early rebleeding rate was significantly varied between the groups with different Hb levels after EVL. Multivariate logistic analysis revealed that restrictive blood transfusion (OR = 4.61, 95% CI: 1.06-19.99; P = .041), Hb (OR = 0.96, 95% CI: 0.95-0.97; P < .001), and Child-Pugh class C (OR = 6.37, 95% CI: 1.28-31.67; P = .024) were identified as independent factors influencing early rebleeding. Our findings suggest that the risk of early rebleeding in cirrhotic patients after EVL may be increased by restrictive blood transfusion, and this should be further investigated in future research.

Risk Factors for Rebleeding After Endoscopic Injection of Cyanoacrylate Glue for Gastric Varices: A Systematic Review and Meta-Analysis

BACKGROUND

Rebleeding is a significant complication of endoscopic injection of cyanoacrylate in gastric varices in cirrhotic patients.

AIM

This systematic review and meta-analysis aimed to evaluate the efficiency of endoscopic cyanoacrylate injection and summarized the risk factors for rebleeding.

METHODS

Databases were searched for articles published between January 2012 and December 2022. Studies evaluating the efficiency of endoscopic injection of cyanoacrylate glue for gastric varices and the risk factors for rebleeding were included.

RESULTS

The final analysis included data from 24 studies. The hemostatic rates ranged from 65 to 100%. The pooled rate of gastric varices recurrence was 34% [95% CI 21-46, I2 = 61.4%], early rebleeding rate was 16% [95% CI 11-20, I2 = 37.4%], late rebleeding rate was 39% [95% CI 36-42, I2 = 90.9%], mild and moderate adverse events rate were 28% [95% CI 24-31, I2 = 91.6%], 3% [95% CI - 2 to 8, I2 = 15.3%], rebleeding-related mortality rate was 6% [95% CI 2-10, I2 = 0%], all-cause mortality rate was 17% [95% CI 12-22, I2 = 63.6%]. Independent risk factors for gastric variceal rebleeding included portal venous thrombosis, ascites, cyanoacrylate volume, fever/systemic inflammatory response syndrome, red Wale sign, previous history of variceal bleeding, active bleeding and paragastric veins. The use of proton pump inhibitors could be a protective factor.

CONCLUSIONS

Endoscopic cyanoacrylate glue injection is an effective and safe treatment for gastric varices. Cirrhotic patients with the above risk factors may benefit from treatment aimed at reducing portal hypertension, antibiotic prophylaxis, and anticoagulation if they meet the indications.

Effect of endoscopic therapy and drug therapy on prognosis and rebleeding in patients with esophagogastric variceal bleeding

Esophagogastric variceal bleeding (EVB) is one of the common digestive system emergencies with poor prognosis and high rate of rebleeding after treatment. To explore the effects of endoscopic therapy and drug therapy on the prognosis and rebleeding of patients with EVB, and then select better treatment methods to effectively improve the prognosis. From January 2013 to December 2022, 965 patients with EVB who were hospitalized in gastroenterology Department of the 940 Hospital of Joint Logistic Support Forces of PLA were retrospectively analyzed. Patients were divided into endoscopic treatment group (ET, n = 586) and drug treatment group (DT, n = 379). Propensity score matching (PSM) analysis was performed in both groups, and the general information, efficacy and length of hospital stay were recorded. The patients were followed up for 3 months after bleeding control to determine whether rebleeding occurred. There were 286 cases in each group after PSM. Compared with DT group, ET had higher treatment success rate (P < 0.001), lower rebleeding rate (P < 0.001), lower mortality rate within 3 months, and no significant difference in total hospital stay (P > 0.05). Compared with drug therapy, endoscopic treatment of EVB has short-term efficacy advantages, and can effectively reduce the incidence of rebleeding and mortality within 3 months.

Visceral Fat Associated with Worsening of Recurrent Esophageal Varices in Alcoholic/Nonalcoholic Steatohepatitis-Related Liver Cirrhosis

BACKGROUND

Alcoholic steatohepatitis and nonalcoholic steatohepatitis-related liver cirrhosis (ASH/NASH-LC) are major causes of esophageal varices (EVs). However, the association between high visceral fat and exacerbation of EVs remains unclear. The aim of this study was to clarify the association of visceral fat and recurrence rate of EVs in ASH/NASH-LC and to identify independent predictors associated with recurrence.

METHODS

We retrospectively evaluated data from 94 patients who underwent endoscopic injection sclerotherapy for EVs with ASH/NASH-LC. Using the receiver operating characteristic curve for the cut-off value of visceral fat index (VFI; 46.4 cm2/m2), we classified patients as having a high VFI (n = 53) or low VFI (n = 41). Propensity score matching was used to align for background factors, and the recurrence rate of EVs was compared between the two groups. Predictors associated with esophageal variceal recurrence were identified by multivariate analysis. The recurrence rate in patients with viral LC was also investigated.

RESULTS

In the overall analysis, the recurrence rate was significantly higher in the high VFI group than in the low VFI group (P = 0.023). The recurrence rate was also higher in the high VFI group than in the low VFI group after propensity score matching, in which 19 patients were matched in each group (P = 0.048). VFI and Child-Pugh score were independently associated with recurrence. Recurrence rates were comparable between the two groups in viral LC patients.

CONCLUSIONS

Worsening of variceal recurrence was observed in high visceral fat patients in ASH/NASH-LC but not in viral LC. Furthermore, high visceral fat was an independent predictor associated with variceal recurrence.

Guidelines for the Management of Esophagogastric Variceal Bleeding in Cirrhotic Portal Hypertension

To standardize the diagnosis, treatment, and management of esophagogastric variceal bleeding (EVB) in patients with cirrhotic portal hypertension, the Chinese Society of Hepatology, the Chinese Society of Gastroenterology, and the Chinese Society of Digestive Endoscopy of the Chinese Medical Association brought together relevant experts, reviewed the latest national and international progress in clinical research on EVB in cirrhotic portal hypertension, and followed evidence-based medicine to update the Guidelines on the Management of EVB in Cirrhotic Portal Hypertension. The guidelines provide recommendations for the diagnosis, treatment, and management of EVB in cirrhotic portal hypertension and with the aim to improve the level of clinical treatment of EVB in patients with cirrhotic portal hypertension.

Diagnosis and Management of Esophagogastric Varices

Acute variceal bleeding (AVB) is a potentially fatal complication of clinically significant portal hypertension and is one of the most common causes of acute upper gastrointestinal bleeding. Thus, esophagogastric varices represent a major economic and population health issue. Patients with advanced chronic liver disease typically undergo an upper endoscopy to screen for esophagogastric varices. However, upper endoscopy is not recommended for patients with liver stiffness < 20 KPa and platelet count > 150 × 109/L as there is a low probability of high-risk varices. Patients with high-risk varices should receive primary prophylaxis with either nonselective beta-blockers or endoscopic band ligation. In cases of AVB, patients should receive upper endoscopy within 12 h after resuscitation and hemodynamic stability, whereas endoscopy should be performed as soon as possible if patients are unstable. In cases of suspected variceal bleeding, starting vasoactive therapy as soon as possible in combination with endoscopic treatment is recommended. On the other hand, in cases of uncontrolled bleeding, balloon tamponade or self-expandable metal stents can be used as a bridge to more definitive therapy such as transjugular intrahepatic portosystemic shunt. This article aims to offer a comprehensive review of recommendations from international guidelines as well as recent updates on the management of esophagogastric varices.

Technique innovation of endoscopic ultrasound portal pressure gradient measurement using standard manometer set for portal hypertension assessment

Portal hypertension (PH) is still a major challenge to be managed in clinical practice. However, hepatic vein pressure gradient (HVPG) measurement is not always reliable for portal hypertension (PH) diagnosis. This study showed the impact of endoscopic ultrasound (EUS) as a promising tool for diagnosis and management PH condition.

Successful Percutaneous Transhepatic Obliteration Plus Sengstaken-Blakemore Tube Combination Therapy for Recurrent Gastroesophageal Variceal Bleeding: A Case Report

We treated a case of gastroesophageal varices due to decompensated liver cirrhosis associated with Wilson's disease. The varicose veins penetrated the paraesophageal vein. We performed endoscopic variceal ligation (EVL) on the perforating vein and endoscopic injection sclerotherapy (EIS) distally. However, 5 days after treatment, the patient vomited blood. Esophagogastroduodenoscopy showed bleeding from the ulcer after EVL at the perforating vein. We performed EVL and stopped the bleeding. However, the next day, she vomited blood again and developed hemorrhagic shock. We were able to achieve hemostasis and save the patient's life with combination therapy consisting of percutaneous transhepatic obliteration and Sengstaken-Blakemore tube placement.

The role of endoscopic ultrasound for portal hypertension in liver cirrhosis

Chronic liver disease is still a major problem because disease progression will ultimately lead to liver cirrhosis. Portal hypertension is the hallmark in advanced liver disease management. By establishing portal vein access, endoscopic ultrasound (EUS) has been utilized in various clinical applications. In comparison to standard upper gastrointestinal endoscopy, EUS-Doppler has been shown to be a better modality for detecting esophageal and gastric varices along with peri-esophageal collateral veins, para-esophageal collateral veins, and perforating veins, and may be used to objectively predict the recurrence of bleeding. EUS-guided portal vein catheterization has also been proposed to overcome the limitations of trans-jugular approaches. The combination of EUS-elastography and azygos vein evaluation can also enhance the diagnostic accuracy of each modality. Another well-known implementation of EUS-guided procedures is in the management of ascites; particularly in paracentesis and ascitic fluid analysis. In addition, the most common clinical application of EUS in the treatment of portal hypertension is through vascular therapy or creation of intrahepatic portosystemic shunts. Major drawbacks of EUS mainly revolve around technical difficulties, the high cost of the procedure, as well as the requirement of more studies in humans to evaluate EUS-guided advanced therapeutic modalities in portal hypertension.

Impact of endoscopic ultrasound examination for deep esophageal collateral veins evaluation in liver cirrhosis patients prior to endoscopic treatment: A case series

Aim

The presence of esophageal collateral veins (ECV) has been reported to be associated with the recurrence of esophageal varices (EV) and bleeding in liver cirrhotic (LC) patients. This study aimed to see the potential clinical value of deep collateral veins assessment using endoscopic ultrasound (EUS) in liver cirrhotic patients with EV.

Methods

During 6 months period, a prospective study is conducted, where we identified LC patients who were admitted for esophagogastroduodenoscopy (EGD) screening at the Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Jakarta. ECV was examined using EUS. Patients were excluded if they had (1) liver malignancy, (2) history of ligation or glue injection, or (3) portal or splenic vein thrombus. We collected demographic data, medical history, data pertaining to use of nonselective beta blocker (NSBB), and laboratory, imaging, and endoscopy results. EGD was performed using a gastroscope (EG29‐i10, 3.2 mm Pentax Medical) while EUS was performed using a linear array echoendoscope (EG‐3870UTK, 3.8 mm, Pentax Medical) before band ligation or glue injection.

Results

There were 20 LC patients included in this study, where 15 (75%) of patients were classified with Child–Pugh (CP)‐A and five (25%) of patients with CP‐B. The most common aetiologies were hepatitis B in seven (35%) patients and hepatitis C in nine (45%) patients. The EV with peri‐ or para‐esophageal veins (PEEV or PAEV) were detected in 65% of patients. None of the LC patients with no EV showed the presence of ECV. PEEV or PAEV were detected in grades 1–3 EV.

Conclusion

EUS examination can give a better evaluation before managing gastroesophageal varices through deep ECV detection in LC patients.

Endoscopic Treatment of Esophageal Varices

Acute variceal bleeding is a complication of portal hypertension, usually due to cirrhosis, with high morbidity and mortality. There are 3 scenarios for endoscopic treatment of esophageal varices: prevention of first variceal bleed, treatment of active variceal bleed, and prevention of rebleeding. Patients with cirrhosis should be screened for esophageal varices. Recommended endoscopic therapy for acute variceal bleeding is endoscopic variceal banding. Although banding is the first-choice treatment, sclerotherapy may have a role. Treatment with Sengstaken-Blakemore tube or self-expanding covered metallic esophageal stent can be used for acute variceal bleeding refractory to standard pharmacologic and endoscopic therapy.

Risk Factors for Esophageal Collateral Veins in Cirrhosis with and without Previous Endoscopic Esophageal Variceal Therapy

BACKGROUND

Portosystemic collateral vessels are a sign of portal hypertension in liver cirrhosis. Esophageal collateral veins (ECVs) are one major type of portosystemic collateral vessels, which increase the recurrence of esophageal varices and bleeding after variceal eradication. However, the risk factors for ECVs were still unclear.

METHODS

We retrospectively screened cirrhotic patients who had contrast-enhanced computed tomography (CT) images to evaluate ECVs and upper gastrointestinal endoscopic reports to evaluate gastroesophageal varices at our department. Univariate and multivariate logistic regression analyses were performed to explore the independent risk factors for ECVs. Odds ratios (ORs) were calculated. Subgroup analyses were performed in patients with and without previous endoscopic variceal therapy which primarily included endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS).

RESULTS

Overall, 243 patients were included, in whom the prevalence of ECVs was 53.9%. The independent risk factors for ECVs were hepatitis C virus infection (OR = 0.250, p = 0.026), previous EVL (OR = 1.929, p = 0.044), platelet (OR = 0.993, p = 0.008), and esophageal varices needing treatment (EVNTs) (OR = 2.422, p = 0.006). The prevalence of ECVs was 60.8% (73/120) in patients undergoing EVL, 50% (10/20) in those undergoing EIS, and 47.5% (48/101) in those without previous endoscopic variceal therapy. The independent risk factors for ECVs were the use of nonselective beta-blockers (OR = 0.294, p = 0.042) and EVNTs (OR = 3.714, p = 0.006) in subgroup analyses of patients with and without previous endoscopic variceal therapy, respectively.

CONCLUSIONS

The presence of ECVs should be closely associated with the severity of portal hypertension in liver cirrhosis. Risk of ECVs might be increased by previous EVL.

Endoscopic Treatment as the Rescue Therapy for Recurrent Bleeding after Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Background

Transjugular intrahepatic portosystemic shunt (TIPS) is suggested as the salvage therapy for gastroesophageal variceal bleeding in cirrhosis. However, rebleeding might occur in some patients after TIPS. Currently, there is a lack of evidence in the endoscopic management of recurrent bleeding in these patients.

Aims

To evaluate the efficacy of endoscopic treatment in cirrhotic patients with recurrent bleeding after TIPS.

Methods

Cirrhotic patients with gastroesophageal varices who received endoscopic treatment for recurrent bleeding after TIPS were included.

Results

6 patients were enrolled in this study. The median age of the patients was 47 years (range 27 to 65 years), and the duration of follow-up time was 346 (17-773) days. Stent stenosis or occlusion was found in 5 out of 6 patients after TIPS. Salvage endoscopic treatment, including esophageal variceal ligation (EVL), gastric variceal cyanoacrylate injection, esophageal variceal sclerotherapy, and balloon-occluded retrograde transvenous obliteration- (BRTO-) assisted endoscopic cyanoacrylate injection. Among included patients, 2 died shortly after EVL (14 and 19 days) due to variceal bleeding. Among other 4 patients, 2 had rebleeding episodes at 422 and 789 days, respectively.

Conclusion

Endoscopic treatment may be an option for recurrent bleeding after TIPS in selected patients. Further studies are needed to carefully define the indication and efficacy of this option.

Efficacy and Safety of Ligation Combined With Sclerotherapy for Patients With Acute Esophageal Variceal Bleeding in Cirrhosis: A Meta-Analysis

Objective: To evaluate the efficacy and safety of endoscopic variceal ligation + endoscopic injection sclerotherapy (EVL+EIS) to control acute variceal bleeding (AVB). Methods: Online databases, including Web of Science, PubMed, the Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), China Biology Medicine (CBM) disc, VIP, and Wanfang, were searched to identify the studies comparing the differences between EVB+EIS and EVB, EIS from the inception of the databases up to December 30, 2020. STATA 13.0 was used for the meta-analysis. Results: A total of eight studies involving 595 patients (317 patients in the EVL group and 278 patients in the EVL+EIS group) were included. The results of the meta-analysis did not reveal any statistically significant differences in the efficacy of acute bleeding control (P = 0.981), overall rebleeding (P = 0.415), variceal eradication (P = 0.960), and overall mortality (P = 0.314), but a significant difference was noted in the overall complications (P = 0.01). Conclusion: EVL is superior to the combination of EVL and EIS in safety, while no statistically significant differences were detected in efficacy. Further studies should be designed with a large sample size, multiple centers, and randomized controlled trials to assess both clinical interventions.

The Role of Endoscopic Ultrasound for Esophageal Varices

Esophageal varices are caused by the development of collateral circulation in the esophagus as a result of portal hypertension. It is important to administer appropriate preventive treatment because bleeding varices can be fatal. Esophageal varices have complex and diverse hemodynamics, and there are various variations for each case. Endoscopic ultrasound (EUS) can estimate the hemodynamics of each case. Therefore, observation by EUS in esophageal varices provides useful information, such as safe and effective treatment selection, prediction of recurrence, and appropriate follow-up after treatment. Although treatment for the esophagogastric varices can be performed without EUS imaging, understanding the local hemodynamics of the varices using EUS prior to treatment will lead to more safe and effective treatment. EUS observation is an indispensable tool for thorough variceal care.

Results of liver and spleen endoscopic ultrasonographic elastography predict portal hypertension secondary to chronic liver disease

Background and study aims  Assessment of endoscopic ultrasonography (EUS)-elastography of the liver and spleen may identify patients with portal hypertension secondary to chronic liver disease. We aimed to evaluate use of EUS-elastography of the liver and spleen in identification of portal hypertension in patients with chronic liver disease. Patients and methods  This was a single-center, diagnostic cohort study. Consecutive patients with liver cirrhosis and portal hypertension underwent EUS-elastography of the liver and spleen. Patients without a history of liver disease were enrolled as controls. The primary outcome was diagnostic yield of liver and spleen stiffness measurement via EUS-elastography in prediction of portal hypertension secondary to chronic liver cirrhosis. Cutoff values were defined through Youden's index. Overall accuracy was calculated for parameters with an area under the receiver operating characteristic (AUROC) curve ≥ 80 %. Results  Among the 61 patients included, 32 had cirrhosis of the liver. Liver and spleen stiffness was measured by the strain ratio and strain histogram, with sensitivity/(1 - specificity) AUROC values ≥ 80 %. For identification of patients with cirrhosis and portal hypertension, the liver strain ratio (SR) had a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 84.3 %, 82.8 %, 84.4 %, and 82.8 %, respectively; the liver strain histogram (SH) had values of 87.5 %, 69.0 %, 75.7 %, and 83.3 %, respectively. EUS elastography of the spleen via the SR reached a sensitivity, specificity, PPV, and NPV of 87.5 %, 69.0 %, 75.7 %, and 83.3 %, respectively, whereas the values of SH were 56.3 %, 89.7 %, 85.7 %, and 65.0 %, respectively. Conclusion  Endoscopic ultrasonographic elastography of the liver and spleen is useful for diagnosis of portal hypertension in patients with cirrhosis.

Esophageal collateral veins in predicting esophageal variceal recurrence and rebleeding after endoscopic treatment: a systematic review and meta-analysis

BACKGROUND

Endoscopic treatment is recommended for the management of esophageal varices. However, variceal recurrence or rebleeding is common after endoscopic variceal eradication. Our study aimed to systematically evaluate the prevalence of esophageal collateral veins (ECVs) and the association of ECVs with recurrence of esophageal varices or rebleeding from esophageal varices after endoscopic treatment.

METHODS

We searched the relevant literature through the PubMed, EMBASE, and Cochrane Library databases. Prevalence of paraesophageal veins (para-EVs), periesophageal veins (peri-EVs), and perforating veins (PVs) were pooled. Risk ratio (RR) and odds ratio (OR) with 95% confidence intervals (CIs) were calculated for cohort studies and case-control studies, respectively. A random-effects model was employed. Heterogeneity among studies was calculated.

RESULTS

Among the 532 retrieved papers, 28 were included. The pooled prevalence of para-EVs, peri-EVs, and PVs in patients with esophageal varices was 73%, 88%, and 54%, respectively. The pooled prevalence of para-EVs and PVs in patients with recurrence of esophageal varices was 87% and 62%, respectively. The risk for recurrence of esophageal varices was significantly increased in patients with PVs (OR = 9.79, 95% CI: 1.95-49.22, P = 0.006 for eight case-control studies), but not in those with para-EVs (OR = 4.26, 95% CI: 0.38-38.35, P = 0.24 for four case-control studies; RR = 1.81, 95% CI: 0.83-3.97, P = 0.14 for three cohort studies). Patients with para-EVs had a significantly higher incidence of rebleeding from esophageal varices (RR = 13.00, 95% CI: 2.43-69.56, P = 0.003 for two cohort studies). Statistically significant heterogeneity was notable across the meta-analyses.

CONCLUSIONS

ECVs are common in patients with esophageal varices. Identification of ECVs could be helpful for predicting the recurrence of esophageal varices or rebleeding from esophageal varices after endoscopic treatment.

Management of patients with liver derangement during the COVID-19 pandemic: an Asia-Pacific position statement

The COVID-19 pandemic has spread rapidly worldwide. It is common to encounter patients with COVID-19 with abnormal liver function, either in the form of hepatitis, cholestasis, or both. The clinical implications of liver derangement might be variable in different clinical scenarios. With growing evidence of its clinical significance, it would be clinically helpful to provide practice recommendations for various common clinical scenarios of liver derangement during the COVID-19 pandemic. The Asia-Pacific Working Group for Liver Derangement during the COVID-19 Pandemic was formed to systematically review the literature with special focus on the clinical management of patients who have been or who are at risk of developing liver derangement during this pandemic. Clinical scenarios covering the use of pharmacological treatment for COVID-19 in the case of liver derangement, and assessment and management of patients with chronic hepatitis B or hepatitis C, non-alcoholic fatty liver disease, liver cirrhosis, and liver transplantation during the pandemic are discussed.

Computed tomography vs liver stiffness measurement and magnetic resonance imaging in evaluating esophageal varices in cirrhotic patients: A systematic review and meta-analysis

BACKGROUND

Computed tomography (CT), liver stiffness measurement (LSM), and magnetic resonance imaging (MRI) are non-invasive diagnostic methods for esophageal varices (EV) and for the prediction of high-bleeding-risk EV (HREV) in cirrhotic patients. However, the clinical use of these methods is controversial.

AIM

To evaluate the accuracy of LSM, CT, and MRI in diagnosing EV and predicting HREV in cirrhotic patients.

METHODS

We performed literature searches in multiple databases, including PubMed, Embase, Cochrane, CNKI, and Wanfang databases, for articles that evaluated the accuracy of LSM, CT, and MRI as candidates for the diagnosis of EV and prediction of HREV in cirrhotic patients. Summary sensitivity and specificity, positive likelihood ratio and negative likelihood ratio, diagnostic odds ratio, and the areas under the summary receiver operating characteristic curves were analyzed. The quality of the articles was assessed using the quality assessment of diagnostic accuracy studies-2 tool. Heterogeneity was examined by Q-statistic test and I 2 index, and sources of heterogeneity were explored using meta-regression and subgroup analysis. Publication bias was evaluated using Deek's funnel plot. All statistical analyses were conducted using Stata12.0, MetaDisc1.4, and RevMan5.3.

RESULTS

Overall, 18, 17, and 7 relevant articles on the accuracy of LSM, CT, and MRI in evaluating EV and HREV were retrieved. A significant heterogeneity was observed in all analyses (P < 0.05). The areas under the summary receiver operating characteristic curves of LSM, CT, and MRI in diagnosing EV and predicting HREV were 0.86 (95% confidence interval [CI]: 0.83-0.89), 0.91 (95%CI: 0.88-0.93), and 0.86 (95%CI: 0.83-0.89), and 0.85 (95%CI: 0.81-0.88), 0.94 (95%CI: 0.91-0.96), and 0.83 (95%CI: 0.79-0.86), respectively, with sensitivities of 0.84 (95%CI: 0.78-0.89), 0.91 (95%CI: 0.87-0.94), and 0.81 (95%CI: 0.76-0.86), and 0.81 (95%CI: 0.75-0.86), 0.88 (95%CI: 0.82-0.92), and 0.80 (95%CI: 0.72-0.86), and specificities of 0.71 (95%CI: 0.60-0.80), 0.75 (95%CI: 0.68-0.82), and 0.82 (95%CI: 0.70-0.89), and 0.73 (95%CI: 0.66-0.80), 0.87 (95%CI: 0.81-0.92), and 0.72 (95%CI: 0.62-0.80), respectively. The corresponding positive likelihood ratios were 2.91, 3.67, and 4.44, and 3.04, 6.90, and2.83; the negative likelihood ratios were 0.22, 0.12, and 0.23, and 0.26, 0.14, and 0.28; the diagnostic odds ratios were 13.01, 30.98, and 19.58, and 11.93, 49.99, and 10.00. CT scanner is the source of heterogeneity. There was no significant difference in diagnostic threshold effects (P > 0.05) or publication bias (P > 0.05).

CONCLUSION

Based on the meta-analysis of observational studies, it is suggested that CT imaging, a non-invasive diagnostic method, is the best choice for the diagnosis of EV and prediction of HREV in cirrhotic patients compared with LSM and MRI.